What is the best treatment approach for a patient presenting with a runny nose?

Treatment of Runny Nose (Rhinorrhea)

For a patient presenting with runny nose, start with intranasal corticosteroids as first-line therapy for moderate to severe symptoms, or use second-generation oral antihistamines for mild symptoms dominated by sneezing and itching. 1, 2

Initial Assessment: Determine the Cause

Before treating, distinguish between the three main causes of runny nose, as treatment differs significantly:

• Allergic rhinitis: Look for clear rhinorrhea, nasal congestion, pale nasal mucosa, itchy nose/eyes, sneezing, and red watery eyes. Symptoms often correlate with allergen exposure (seasonal patterns, pet exposure, dust). 1
• Viral rhinitis (common cold): Self-limited illness with rhinorrhea, sneezing, sore throat, and cough. Symptoms typically peak within 3 days and resolve within 10-14 days. Fever and myalgia resolve by day 5. 3
• Nonallergic rhinitis: Primarily nasal congestion and postnasal drainage without itching or eye symptoms. Negative allergy testing. 4

Treatment Algorithm for Allergic Rhinitis

Mild Intermittent Symptoms (< 4 days/week or < 4 weeks/year)

Start with second-generation oral antihistamines for patients whose primary complaints are sneezing, itching, and runny nose: 1, 4

• Cetirizine, fexofenadine, loratadine, or desloratadine 1, 5
• These are preferred over first-generation antihistamines (diphenhydramine) which cause significant sedation, performance impairment, and anticholinergic effects 1, 6
• Critical caveat: Oral antihistamines have minimal effect on nasal congestion 7, 8

Moderate to Severe or Persistent Symptoms (> 4 days/week and > 4 weeks/year)

Initiate intranasal corticosteroids immediately as first-line monotherapy: 1, 2, 4

• Fluticasone, mometasone, budesonide, or triamcinolone at 200 mcg daily (2 sprays per nostril once daily) 2
• These are the most effective monotherapy for controlling all major symptoms including rhinorrhea, congestion, sneezing, and itching 2, 8, 9
• Must be used daily at regular intervals, not as-needed 10
• Direct spray away from the nasal septum to prevent mucosal erosions and potential septal perforation 2

If Inadequate Response After 2-4 Weeks

Add intranasal antihistamine (azelastine or olopatadine) to the intranasal corticosteroid: 2, 10, 4

• This combination provides superior symptom reduction (37.9% vs 29.1% for intranasal corticosteroid alone) 10
• Intranasal antihistamines are equal to or superior to oral antihistamines for seasonal allergic rhinitis 1
• Note: Intranasal antihistamines may cause sedation due to systemic absorption 1

For Severe Nasal Congestion Preventing Medication Penetration

Add topical oxymetazoline for maximum 3 days only: 2, 10

• This allows the intranasal corticosteroid to reach nasal mucosa effectively 10
• Critical warning: Limit to 3 days maximum to prevent rhinitis medicamentosa (rebound congestion) 2, 11

Treatment for Viral Rhinitis (Common Cold)

Do NOT prescribe antibiotics—they are completely ineffective for viral illness: 3

Provide symptomatic relief with: 3

• Acetaminophen or ibuprofen for pain and fever 3
• Nasal saline irrigation to relieve congestion and facilitate secretion clearance 3
• Topical intranasal corticosteroids for modest symptom relief 3
• Optional: Oral decongestants (use cautiously in hypertension/anxiety) or topical decongestants (maximum 3-5 days) 3

For isolated rhinorrhea in viral infections:

• Intranasal ipratropium (anticholinergic) effectively reduces rhinorrhea but has no effect on other symptoms 2, 3
• Do NOT use antihistamines expecting rhinorrhea reduction—evidence shows they don't work for this indication in viral infections 3

Critical Pitfalls to Avoid

• Never use first-generation antihistamines without warning patients about sedation, performance impairment, and anticholinergic effects (urinary retention in BPH, contraindicated in elderly) 1, 2
• Never use topical decongestants beyond 3-5 days—rhinitis medicamentosa will develop, worsening congestion 2, 11
• Never prescribe antibiotics for viral rhinitis or colored nasal discharge alone—color reflects neutrophils, not bacterial infection 3
• Never rely on oral antihistamines as monotherapy for patients with significant nasal congestion—they have minimal decongestant effect 7, 8
• Avoid oral decongestants in patients with coronary heart disease, hypertension, or BPH due to cardiovascular and anticholinergic effects 2

When to Refer or Consider Immunotherapy

Refer to allergist/immunologist if: 1, 2

• Inadequate response to optimal pharmacotherapy after 2-4 weeks 10
• Need for allergen immunotherapy (sublingual or subcutaneous)—the only treatment that modifies the natural history of allergic rhinitis and may prevent asthma development 1, 2
• Specific IgE testing needed when diagnosis is uncertain or empiric treatment fails 1

Environmental Control Measures

Advise allergen avoidance when specific triggers are identified: 1

• Limit outdoor exposure during high pollen counts 1
• Remove moisture sources and use dilute bleach on nonporous surfaces for fungal control 1
• Combination of humidity control, dust mite covers, HEPA vacuuming, and acaricides for dust mite allergy 1
• Complete pet removal for animal sensitivity 1